///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Obstetric Management of a Parturient with Cortical Vein Thrombosis

Abstract Number: 219
Abstract Type: Case Report/Case Series

Jennifer L McGinley M.D.1 ; Sivam Ramanathan M.D.2; Jeff Stone M.D.3; Mark Zakowski M.D.4

A 38-year-old G1P0 parturient presented to the obstetric service with sudden onset of severe headache, altered mental status and bouts of projectile vomiting. Magnetic resonance imaging (MRI) studies showed a right frontal lobe lesion with hemorrhage expanding across the rostrum and genu of the corpus callosum with intraventricular extension. There was no midline shift or papilledema. A decision was made to quickly deliver the baby surgically so definitive treatment of the intracranial lesion could proceed. The case was discussed with the neurosurgeon, who requested avoidance of general anesthesia in order to allow continuous intraoperative assessment of mental status. A decision was made to perform epidural anesthesia in order to minimize hemodynamic and neuraxial pressure changes by using incremental doses. Epidural anesthesia would also allow us to avoid a breech in the dura, which theoretically might carry a small risk of herniation.

In the sitting position, an epidural catheter was placed for surgical anesthesia. Incremental dosing through the catheter produced worsening of the patients symptoms. Subsequent aliquots (3 ml) were thus reduced in volume. The patient ultimately received 25 mL of 2% lidocaine with epinephrine 1:200,000 in order to produce a sensory level to T4. Successful operative delivery was carried out without incident.

Postoperatively, magnetic resonance venography (MRV) revealed a dural venous sinus thrombosis and hemorrhage. The patient was placed on antiseizure and anticoagulation therapy and placed in the ICU. Her hospital course was complicated by fevers and cognitive impairment. After some improvement, she was discharged home on hospital day 25 with persistent cognitive impairment requiring in home assistance. She continued to take warfarin and a follow up MRI 4 months later showed no remaining lesion. Her neurologic function continues to improve.

This case is presented to highlight the diagnosis and management of a patient with antepartum cortical vein thrombosis, a rare but life-threatening condition associated with pregnancy. Its etiology is multifactorial. Once present, cortical vein thrombosis presents challenges for the anesthesiologist and obstetrician alike regarding safe peripartum management.

SOAP 2009